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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
GSIU-AP8PZX

FACILITY NAME
Pomegranate Childcare
SERVICE TYPES
301 Group Child Care (under 36 months)
FACILITY LICENSE #
NGIL-AKNMVX
FACILITY ADDRESS
7289 Gray Ave
FACILITY PHONE
(604) 757-9629
CITY
Burnaby
POSTAL CODE
V5J 3Z1
MANAGER
Chu Ying Chen (Mandy)

INSPECTION DATE
July 13, 2017
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2.75
ARRIVAL
10:30 AM
DEPARTURE
01:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED
3

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care & Assisted Living Act (CCALA), the Child Care Licensing Regulation (CCLR) and the relevant Director of Licensing Standards of Practice (DOLSP). Evidence for this report was based on the Licensing Officer’s observations, review of the facility records and information provided by the facility staff at the time of inspection.
The following areas were reviewed:
· Licensing
· Physical Facility
· Staffing
· Polices & Procedures
· Care & Supervision
· Hygiene and Communicable Disease Control
· Medication
· Nutrition and Food Services
· Program
· Records and Reporting
As part of the routine inspection a Facility Risk Assessment Tool is completed and a copy is provided. The Risk Assessment includes non-compliance identified during the routine inspection and a 3 year “historical” review of the facility’s compliance and operation.
Visit the CCFL website at http://www.fraserhealth.ca/childcare for:
· Additional resources and
· Links to the Legislation (CCALA & CCLR)
Useful websites to consider:
Criminal Record Checks: www2.gov.bc.ca/gov/content/safety/crime-prevention/criminal-record-check
ECE Registry: www.mcf.gov.bc.ca/childcare/ece
If you have any questions regarding this report feel free to contact me at 604-918-7526 or email gurinderjeet.sidhu@fraserhealth.ca

Contraventions
Previous Inspection - Not Applicable
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
STAFFING: 12010 - CCALA s.7(1)(d) - A licensee must do all of the following: (d) appoint a manager for the community care facility.
Observation: Licensing staff noted that facility has no manager appointed. Licensee stated that the manager has left the facility to work at another centre. Licensing discussed with the licensee about the requirement and qualifications/documentation for the manager. Licensee will be sending an application to appoint a new manager for the facility.
Corrective Action(s): Ensure that a manager is appointed for a community care facility.
Date to be Corrected: July 20, 2017

STAFFING: 12040 - CCLR s.19(1)(a) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has first met with the person and obtained all of the following: (a) a criminal record check for the person.
Observation: Review of staff files noted that one staff has no Criminal record clearance(CRC) on file and other staff has CRC from her school. Licensing told the licensee that CRC needs to be site specific and CRC sharing can be done to have site specific CRC.
Corrective Action(s): Ensure all staff files are complete and current.
Date to be Corrected: July 20, 2017

STAFFING: 12050 - CCLR s.19(1)(b) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has first met with the person and obtained all of the following: (b) character references in respect of the person.
Observation: Review of staff files noted that one staff who was working at the time of inspection did not have a reference on file.
Corrective Action(s): Ensure all staff files are complete
Date to be Corrected: July 20, 2017

STAFFING: 12060 - CCLR s.19(1)(c) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has first met with the person and obtained all of the following: (c) a record of the person's work history.
Observation: One of two staff working at the time of inspection has no documentation available on staff files to review.
Corrective Action(s): Ensure all staff files are complete.
Date to be Corrected: July 20, 2017

STAFFING: 12070 - CCLR s.19(1)(d) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has first met with the person and obtained all of the following: (d) copies of any diplomas, certificates or other evidence of the person's training and skills.
Observation: There were two staff working in the facility at the time of inspection and none of the staff has any evidence of training or diploma certificates. ECE diploma and first aid certificate was not on file. One staff said she recently completed her First Aid training and waiting for her certificate.
Corrective Action(s): Ensure all staff files are complete
Date to be Corrected: July 20, 2017

STAFFING: 12090 - CCLR s.19(1)(f) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has first met with the person and obtained all of the following: (f) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: 2 of 3 children have no documentation on file.
Corrective Action(s): Ensure all children files are complete.
Date to be Corrected: July 18, 2017

RECORDS AND REPORTING: 19070 - CCLR s.57(2)(a) - A licensee must keep, for each child, a record showing the following information: (a) name, sex, date of birth, medical insurance plan number and immunization status.
Observation: 2 of 3 children have no documentation on file.
Corrective Action(s): Ensure all children files are complete.
Date to be Corrected: July 18, 2017

RECORDS AND REPORTING: 19080 - CCLR s.57(2)(b) - A licensee must keep, for each child, a record showing the following information: (b) date of enrolment in the community care facility.
Observation: licensing staff noted that 2 of 3 children have no documentation on file. Licensee stated that these children are new and parents did not bring the forms back. Licensing staff advised the licensee to have all the documentation on file prior to enrolling children in care.
Corrective Action(s): Ensure all children file are complete.
Date to be Corrected: July 18, 2017

RECORDS AND REPORTING: 19090 - CCLR s.57(2)(c) - A licensee must keep, for each child, a record showing the following information: (c) daily attendance record, indicating for each day whether the child is absent or, if the child is present, the time of arrival and departure.
Observation: Upon arrival licensing staff noted 2 children in care but one of the child was signed in. There was no sign in/out after July 5. Licensee said that these children are part time. Some of the days there are no children in care.
Corrective Action(s): Ensure all records are complete and current.
Date to be Corrected: July 18, 2017

RECORDS AND REPORTING: 19100 - CCLR s.57(2)(d) - A licensee must keep, for each child, a record showing the following information: (d) name and telephone number of a parent, medical practitioner and emergency contact.
Observation: 2 of 3 children have no documentation on file.
Corrective Action(s): Ensure children file are complete before start date.
Date to be Corrected: July 18, 2017

RECORDS AND REPORTING: 19160 - CCLR s.57(2)(i) - A licensee must keep, for each child, a record showing the following information: (i) a photograph or digital image of the child, and other information that can be used to readily identify the child in an emergency.
Observation: 2 of 3 children have no documentation on file.
Corrective Action(s): Ensure all children files are complete.
Date to be Corrected: July 18, 2017

RECORDS AND REPORTING: 19190 - CCLR s.57(3)(a) - A licensee must have in writing from a parent, and maintain at the community care facility, consent (a) to call a medical practitioner or ambulance in case of accident or illness if the parent cannot immediately be reached.
Observation: None of the children have a signed consent to call medical practitioner or ambulance in case of emergency.
Corrective Action(s): Ensure children files are complete
Date to be Corrected: July 18, 2017

RECORDS AND REPORTING: 19200 - CCLR s.57(3)(b) - A licensee must have in writing from a parent, and maintain at the community care facility, consent (b) to release a child to someone other than the parent.
Observation: Review of children files note 2/3 children have no documentation on file.
Corrective Action(s): Ensure all children files are complete.
Date to be Corrected: July 18, 2017


Comments

One of the staff members is licensee's spouse and she does not have any documentation available for licensing. Licensing staff noted her providing care to the children at the time of inspection. Licensing staff also noted licensee's friend in the day care. Licensee said that she is a teacher and she is only visiting them. Licensing discussed with the licensee that any family members or friends vising them should have no access to the children unless they have criminal records check obtained for the facility.
Discussed at time of this inspection with the Licensee:
Updated Child Care Licensing Regulations, including;
o Licensee’s responsibility to validate and keep a record for all employees including substitutes, (both current and new hires) who hold a valid ECE Certification (ECE, ECE Assistant, I/T ECE & SN ECE).
· New Director of Licensing Standards of Practice for Active Play, including; two new policies to be created and implemented include Active Play and Screen Use Policies
· A copy of Live 5210 was also provided.
Please go to bclaws.ca to review changes to the Child Care Licensing Regulation.
The report was reviewed with Facility Manager prior to signing.
Thank you for your time and cooperation.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into complianceFollow-up Inspection Required
Approximate Follow Up Date

Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.